Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Aims. Periprosthetic joint infections (PJIs) are among the most devastating complications after joint arthroplasty. There is limited evidence on the efficacy of different antiseptic solutions on reducing biofilm burden. The purpose of the present study was to test the efficacy of different antiseptic solutions against clinically relevant microorganisms in biofilm. Methods. We conducted an in vitro study examining the efficacy of several antiseptic solutions against clinically relevant microorganisms. We tested antiseptic irrigants against nascent (four-hour) and mature (three-day) single-species biofilm created in vitro using a drip-flow reactor model. Results. With regard to irrigant efficacy against biofilms, Povidone-iodine treatment resulted in greater reductions in nascent MRSA biofilms (logarithmic reduction (LR) = 3.12; p < 0.001) compared to other solutions. Bactisure treatment had the greatest reduction of mature Pseudomonas aeruginosa biofilms (LR = 1.94; p = 0.032) and a larger reduction than Vashe or Irrisept for mature Staphylococcus epidermidis biofilms (LR = 2.12; p = 0.025). Pooled data for all biofilms tested resulted in Bactisure and Povidone-iodine with significantly greater reductions compared to Vashe, Prontosan, and Irrisept solutions (p < 0.001). Conclusion. Treatment failure in PJI is often due to failure to clear the biofilm; antiseptics are often used as an adjunct to biofilm clearance. We tested irrigants against clinically relevant microorganisms in biofilm in vitro and showed significant differences in efficacy among the different solutions. Further clinical outcome data is necessary to determine whether these solutions can impact PJI outcome in vivo. Cite this article: Bone Joint J 2021;103-B(5):908–915

We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001).

Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S& P) followed by alcohol showed significantly better efficacy over PI (S& P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S& P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.

Cite this article: Bone Joint J 2013;95-B:498–503.

This was a retrospective analysis of the medium- to long-term results of 46 TC3 Sigma revision total knee replacements using long uncemented stems in press-fit mode.

Clinical and radiological analysis took place pre-operatively, at two years post-operatively, and at a mean follow-up of 8.5 years (4 to 12). The mean pre-operative International Knee Society (IKS) clinical score was 42 points (0 to 74), improving to 83.7 (52 to 100) by the final follow-up. The mean IKS score for function improved from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up. At the final follow-up 30 knees (65.2%) had an excellent result, seven (15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor result. There were two failures, one with anteroposterior instability and one with aseptic loosening.

The TC3 revision knee system, when used with press-fit for long intramedullary stems and cemented femoral and tibial components, in both septic and aseptic revisions, results in a satisfactory clinical and radiological outcome, and has a good medium- to long-term survival rate.

We reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54).

The mean modified Harris hip score improved by 19.2 points (95% confidence interval 13.6 to 24.9; p < 0.001) while the mean non-arthritic hip score improved by 15.0 points (95% confidence interval 10.9 to 19.1, p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The overall level of satisfaction was high with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred.

Arthroscopic femoral osteochondroplasty performed in selected patients over 60 years of age, who have hip pain and mechanical symptoms resulting from cam femoroacetabular impingement, is beneficial with a minimal risk of complications at a mean follow-up of 30 months.

In a rabbit model we investigated the efficacy of a silk fibroin/hydroxyapatite (SF/HA) composite on the repair of a segmental bone defect. Four types of porous SF/HA composites (SF/HA-1, SF/HA-2, SF/HA-3, SF/HA-4) with different material ratios, pore sizes, porosity and additives were implanted subcutaneously into Sprague-Dawley rats to observe biodegradation. SF/HA-3, which had characteristics more suitable for a bone substitite based on strength and resorption was selected as a scaffold and co-cultured with rabbit bone-marrow stromal cells (BMSCs). A segmental bone defect was created in the rabbit radius. The animals were randomised into group 1 (SF/HA-3 combined with BMSCs implanted into the bone defect), group 2 (SF/HA implanted alone) and group 3 (nothing implanted). They were killed at four, eight and 12 weeks for visual, radiological and histological study.

The bone defects had complete union for group 1 and partial union in group 2, 12 weeks after operation. There was no formation of new bone in group 3. We conclude that SF/HA-3 combined with BMSCs supports bone healing and offers potential as a bone-graft substitute.

We studied the effects of coating titanium implants with teicoplanin and clindamycin in 30 New Zealand White rabbits which were randomly assigned to three groups. The intramedullary canal of the left tibia of each rabbit was inoculated with 500 colony forming units of Staphylococcus aureus. Teicoplanin-coated implants were implanted into rabbits in group 1, clindamycin-coated implants into rabbits in group 2, and uncoated implants into those in group 3. All the rabbits were killed one week later. The implants were removed and cultured together with pieces of tibial bone and wound swabs. The rate of colonisation of the organisms in the three groups was compared.

Organisms were cultured from no rabbits in group 1, one in group 2 but from all in group 3. There was no significant difference between groups 1 and 2 (p = 1.000). There were significant differences between groups 1 and 3 and groups 2 and 3 (p < 0.001). Significant protection against bacterial colonisation and infection was found with teicoplanin- and clindamycin-coated implants in this experimental model.

Modern principles for the treatment of open fractures include stabilisation of the bone and management of the soft tissues. Wound debridement and irrigation is thought to be the mainstay in reducing the incidence of infection. Although numerous studies on animals and humans have focused on the type of irrigation performed, little is known of the factors which influence irrigation. This paper evaluates the evidence, particularly with regard to additives and the mode of delivery of irrigation fluid.

Normal saline should be used and although many antiseptics and antibiotics have been employed, no consensus has been reached as to the ideal additive. Despite the advocates of high-pressure methods highlighting the improved dilutional ability of such techniques, the results are inconclusive and these irrigation systems are not without complications.

New systems for debridement are currently being investigated, and an ideal method has yet to be determined.

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s.

Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics.

Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p < 0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings.